Provider Demographics
NPI:1053064154
Name:SMITH, CAROLINE WADE (PAC)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:WADE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44045 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5101
Mailing Address - Country:US
Mailing Address - Phone:703-858-6000
Mailing Address - Fax:
Practice Address - Street 1:44045 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5101
Practice Address - Country:US
Practice Address - Phone:703-858-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant